HomeMy WebLinkAbout1584A 1585A (9) /' �ORKERS'COMPENSATION DECIARATION � � � �
� U a ffirm that I have a certifimte of consem to self � e p�L1CAT'OIV FO� �UfLDIN� PE�MIT
�nsur� �r a tertificote of Workers'Compensation Insurance, �-�
_ or y�cerlified copy�thereof��ec.3800.Lab.C.) - _ �
Po�_� /�[i �fL ,� COUNTY OF lOS ANGELES BUILDING AND SAFETY
yN2Y �GO�Company/�JZ) �/A3DEfNL�T. -
� Cerfified copy is bereby furnished. FQR APPUCANT TQ FILL IN BUILDING
ao�rsEss
� .Certified copy is filed with tha county buiiding inspec- BUILDING. � . -
tion deporfineM. ADDRE55 LDdU�flG GGi�Ss �pCq��TY
�afe�'—.�—£rG Applicont A."h•o-�...: c�rv DI�J'/y/B�vD Q�/L na cR�assssr.
�RTIFICATE OF€XEMPTION FROM WORKERS' SIZE�tOT G�X��� t�W ON LDT � MAP BOOK PAGE PARCE[
- COMPENSATION INSURANCE .
. (This sec�ion need not be compleTed if fhe permit is for one - � USE ZONE MAP - �
huadr�doltars(SIOD)w I�s.� Taacr ,5S � siocK iar rio./� . _.. _ Np,
. .. . . . . TEL. . - - SPECIAL
1 cenify tFiW in the perfwmwnce of she work fur which-ihis OWNER- 6 p�p, �Q aZ�L - CONDRIONS _ _ �
permit is isstied,(ahatt not empioy any person in any manner DiSTRICT GROUI� TVVE �F�RE PROCESSEO Bv (5
�o 0810 becOmB au6jec11n the Workers'CompensnNon 1.p�ws. ��� CONSTr;+ 7 � U
y ��� �
Da1e .. . � App iicCM � . . .. CIiY � ZIP STAtI5TIG4l CL455tF ION - � APT. CONDO. O
tJOTICE TO APPLICANT:�R, nftar mnking�this Cxtificuie of ����� ' T� . .... .. . .. . V
�Ezemptio�, you should become sub}ect fa.the��Vlorkers' C1A55 NO. DWF1L 11NIT5� Wa
Compensatiortpravis'uns of fhe Lot�nr Coda,ynu musl forlh- �._. �DDRE55 -___----- ---------/F----------- --.__SEweR-Atnr . ..._._ . .__. _ _ _.._.. ..- .�n
with camply with such provtsions or th�s perm4 shatt be �� �� 2
deemed revoked. ... -- . . q3'7S7I VALlDATION w
corarwacroR . ? __ _ eic. a�.
uceruEo Cotarwicroas oEciawinav C uc 3�¢O�2.
I hereby affirm thak I am IicerEsed uoder prayisfam of Chayter 9 nooREss p � A/ N6. YAIUATfON
r se -
(commendng with Section 7000)of Divisioh 3 of ihe @usioasx and ... . LIG -
Pcofassions Co�k,u�my licanse�.b irt 4vU fmceand eHect. CITY U$h1 CL4S5 t���d� � -. .
icense Number
'i�40Lt 2 uc.Gns�C L/f Ci� SQEhT. S OR� �a�,ni�L� on� . �
COnho[tor�, W.�A^,L[t rt� Data.. .�`�.—�L OESCRIPTION OF WORK N�ry ❑ S . .
�1 om exempt undw Sec. /IJL1 %Q G' !f� ��_ iJ
� Al1ER � fINAt n.w,��:
. B.BP.C.for fhia reason � R��R � ..DATE -��'V !.,r' �� Jr$,LI.A
oare: e��einc. o� ❑ g�' �'�� #... .2 3
_ y (� /�
� ��ru•�O�E�M BUIL��/��--. ,aw«CaM 7EL. .
-- ���T� � PRINT NO._._ _ � I+�L S.O O
1 hm aKirm thW i�am ax #rom ti�s ConNactors license - - �1C.-D V
� low for the folfowing reawn(SMion 7IX31.5,Businau ond A�Eu - �����. • ' •L�C C c.=i
Profeuio�u Code): _ � -
� �I, of owner of iha property, or my employees with ���q�p�� � - �+��G�&6
woqes as their sole compensoNon,will do the work and �
fhe snudure is rrot intended or offered tor sale(Section ��b`��T`" L� �'5�
704t.Business and Wofessions Code).. mOvit� iEL .
� I,.as owner Qf rhe proper�y._am exclysively con�raciing . .�T� NO. �'�•' • • ��
with licensed conhactora to conshuct the project(Seo- ADDRE55 � • •�'J Q 7�
tion 7W4.Business and Profeuiona Code).
. . . _ ._.. __. -__._..
RE(X11RFD TOTALSETBACKFROM E%IST.
CONSTRUCTION LENUING AGENCY� � � �gq� �Y/Ut0 HWv pRpp,UN Wi�iH � • ° °�J Ct`]rj c*i
i hereby affirm ihat ihere is a construcfion Iending agency for pgpM
the parfwmance of the work for which this permit is issued r.�. D 9:0 2—8 6
is�.�,r,,.c.�. s,o�
_ .... _._ _. .' . . P.L ' .
Lander'a Name . /�(� ._.
$ P.t.Fee f t�l.! Vermit Fee �
�@nt�9f�S�d19S5
� �cenify�that!hove read this application and srore that�tha Iuuance Fee 1
� above informmion is correc�.1 agree ro comply with o�l County ��„��;qanon Fee
ordinontea ond S M lawa relafing b buNding wnshuction, Toml Pee
iY ond heraby aut rize rspresentntivw ot thi:Couniy to errter �
� upon the abo •mentioned prop ms �on p.� .
o � SEE REVEYSE FOR EX►tAMATORY Ui1GUAGi
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